JACC: CARDIOONCOLOGY
VOL. 2, NO. 4, 2020
ª 2020 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Cardio-Oncology in Peru An Emerging Discipline Enrique Ruiz-Mori, MD, PHD,a,b,c Leonor E. Ayala-Bustamante, MD,b Edgar Quispe-Silvestre, MD,b Rowel Rolando Rivas-Flores, MD,b Jorge Burgos-Bustamante, MDa,b
C
ardiovascular disease and cancer are the first
research in oncology. In 1952, because it was the only
and second leading causes of death in Peru,
specialized cancer center in the country and due to
respectively, as is the case in many countries
high patient demand, it was renamed the Instituto
in the region. In Peru, approximately 33,098 cancer
Nacional de Enfermedades Neoplásicas (INEN) (the
deaths were reported in 2019, and 66,627 new cancer
National Institute of Neoplastic Diseases). The pro-
cases were detected, with 60% of such cases in
cess of decentralizing cancer control services and
women. Alarmingly, Peru’s cancer rate has increased
treatment began in 2007, with the aim of improving
by 40% in the last 20 years, from 156 to 229 per
geographic and economic access for Peruvians in the
100,000 live births, which represents a public health
most remote regions in the country, with the opening
crisis that demands greater attention. The most
of 2 hospital centers, 1 located in the north (Trujillo)
frequent cancer in men is prostate cancer (7,598
and the other in the south (Arequipa).
new cases and 2,721 deaths), followed by stomach
The INEN initiated the Budgetary Program for
cancer (5,731 new cases and 4,606 deaths), whereas
Cancer Prevention and Control with the mission of
in women, breast cancer is the most frequent (6,985
providing
new cases and 1,858 deaths), followed by cervical
coverage
cancer (4,103 new cases and 1,836 deaths) (1,2). The
vulnerable populations, by enhancing cancer pre-
increasing cancer prevalence and the epidemiologic
vention, early detection, and treatment in the public
timely, to
all
comprehensive
Peruvians,
cancer
including
the
care most
overlap between cardiovascular disease and cancer
sector (3). In 2012, with the financial support of Peru’s
have resulted in a growing interest in the field of car-
health insurance system, the National Plan for
dio-oncology.
Comprehensive Cancer Care and Improvement of
Long before cardio-oncology developed as a field in
Access to Oncology Services, called Plan Esperanza
Peru, the country’s fight against cancer began. On
(The Hope Plan), was initiated. The Hope Plan made it
May 11, 1939, law number 8892 established the Na-
possible to declare cancer care to be a national in-
tional Cancer Institute, and on December 4, 1939, the
terest and improved access to oncology services
National Cancer Institute was officially inaugurated.
throughout the country (4). The INEN treats approx-
The legislation’s main goal was to improve cancer
imately 12,500 new cancer cases per year, with 10,309
prevention efforts and provide specialized medical
hospitalizations,
assistance, as well as to promote education and
chemotherapy treatments for 63,000 patients, and
6,345
cancer
surgeries,
44,893
approximately 81,337 radiation therapy sessions for 4,295 patients. However, delayed health care access may still have contributed to the death of 63% of From the aUniversidad de San Martín de Porres, Facultad de Medicina Humana, Lima, Perú; bInstituto Nacional de Enfermedades Neoplásicas, c
Unidad de Cardio-Oncología, Lima, Perú; and the Cardiology Service, Instituto Nacional de Enfermedades Neoplásicas.
patients within the first year of their cancer diagnosis in metropolitan Lima, Peru’s capital and largest city. Early diagnosis of most cancer types usually en-
The authors attest they are in compliance with human studies
ables earlier and more effective treatments, thereby
committees and animal welfare regulations of the authors’ institutions
reducing mortality rates. However, to detect cancer at
and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: CardioOncology
early stages, it is necessary to successfully promote
author instructions page.
health education to raise cancer awareness. Just as
ISSN 2666-0873
https://doi.org/10.1016/j.jaccao.2020.10.004
672
Ruiz-Mori et al.
JACC: CARDIOONCOLOGY, VOL. 2, NO. 4, 2020 NOVEMBER 2020:671–3
Cardio-Oncology in Peru
importantly, health services must be available to all
inhibitors (e.g., HER2 targeted therapies), chest radi-
geographic and economic populations, increasing
ation, and immune therapies (9,10).
access to medical staff and equipment to enable ac-
In May 1952, Dr. Ricardo Subiría Carrillo joined the
curate and timely diagnoses and effective treatments.
INEN as the institution’s first cardiologist, evaluating
In Peru, health resources are limited, because very
patients with metastatic cancer to the heart and, less
little is invested in the care of the population. Only 4
frequently, primary cardiac malignancies. He also
countries (the United States, Canada, Costa Rica, and
conducted pre-surgical evaluations of patients who
Uruguay) invest 6% or more of their gross domestic
underwent extensive surgeries. In his 1973 doctoral
product in health care and services, which is the
thesis entitled “Metastatic Neoplasms of the Heart,”
minimum amount recommended by the World Health
he highlighted the significance of cardiac dysfunction
Organization. Countries that invest 4% to 6% include
developing
Honduras, El Salvador, Paraguay, Ecuador, Bolivia,
November 1992, Dr. Enrique Ruiz Mori introduced the
Nicaragua, Colombia, and Panama. Furthermore, the
traditional electrocardiogram, Holter monitor, blood
following countries invest between 2% and 4%:
pressure monitor, and echocardiogram to the cardio-
Guatemala, Argentina, Mexico, Brazil, Peru, and
vascular community, which became fundamental
Chile. Haiti and Venezuela invest <2% (5).
tools to assess cardiac function in patients who un-
In
recent
years,
Peru
has
had
significantly
secondary
to
cancer
therapy.
In
derwent chemotherapy. These tools enabled the first
improved macroeconomic performance compared to
anthracycline-induced
other Latin American countries, ranking sixth ac-
monitoring, and follow-up in Peru. The echocardio-
cardiotoxicity
diagnosis,
cording to gross domestic product (þ2; 16%) (6), after
gram also enabled physicians to quantify the results
Brazil, Mexico, Argentina, Colombia, and Chile.
of cardioprotective drugs such as dexrazoxane to help
Despite Peru’s positive economic growth (private
prevent anthracycline-induced cardiotoxicities and,
consumption: þ3.0%; public consumption: þ2.7%;
later, the toxic effects of the anti-HER2þ agent tras-
private investment: þ4.2%; employment: þ2.0%), its
tuzumab on ventricular function.
health budget has been at only 3%. It is estimated that
Beginning in 2016, cardio-oncology was actively
420,024 healthy life years, or disability-free life ex-
promoted in Peru as an increasingly important med-
pectancy, are lost each year because of cancer in Peru.
ical discipline for the enhanced care of cancer pa-
Of these, 27,929 are due to breast cancer and 44,924
tients through the development of courses at the
are due to cervical cancer (7,8). In 2012 in Peru, there
INEN and, subsequently, participation in national and
were 21 cancer health facilities in 9 regions of the
international cardiology congresses. Likewise, medi-
country, and in 2016, there were 43 cancer health
cal researchers in Peru began to publish on important
facilities in 18 regions. This increase reflects the
cardio-oncology topics. In 2018, the first cardio-
growing need for diagnostic and treatment programs
oncology manual of the South American Society of
that also address the widening health gap between
Cardiology was published (11), with subspecialists
rural, indigenous, and low-income areas as compared
Gina Gonzalez (Colombia), Carlos Lax (Argentina),
with urban, developed, high-income areas.
Pamela
Rojo
(Chile),
Ariane
Scarlatelli
Macedo
Research advances have resulted in the develop-
(Brazil), Horacio Vásquez (Uruguay), Vicente Villa-
ment of new antineoplastic drugs with increased ef-
creces (Ecuador), and Bartolomé Finizola (Venezuela)
ficacy and, in some cases, leading to cures for
collaborating on this project. Peru was represented by
previously difficult-to-treat cancers. For example,
an oncologist, a radiotherapist, an electrophysiolo-
survival for early-stage breast cancer has reached 87%
gist, and 3 cardiologists from INEN.
in Brazil, 76% in Colombia, and 83% in Ecuador. In
On February 19, 2019, 5 cardiologists, 4 nurses, and
Peru, approximately 150,000 women have been suc-
4 technicians at the INEN launched the first cardio-
cessfully treated for breast cancer. However, cancer
oncology unit in the country, with a monthly demand
treatments may also be associated with adverse
of 750 evaluations, either outpatient, hospitalized, or
events and toxicities. Some of the first reports of the
ICU patients and more than 300 echocardiographic
cardiotoxicities associated with the use of the
studies. The main goal of the cardio-oncology unit is to
anthracycline daunorubicin were published in 1967.
consolidate efforts to enhance the safety and efficacy
There is now increasing knowledge regarding these
of cancer patient care through a coordinated, multi-
potential acute, chronic, and late effects associated
disciplinary approach by oncologists, hematologists,
with
5-
radiotherapists, oncology surgeons, cardiologists,
fluorouracil, monoclonal antibodies, and tyrosine
nurses, health care providers, and technical staff as
certain
cancer
treatments,
including
Ruiz-Mori et al.
JACC: CARDIOONCOLOGY, VOL. 2, NO. 4, 2020 NOVEMBER 2020:671–3
Cardio-Oncology in Peru
well as to promote and establish new cardio-oncology
necessity in Peru, throughout South America, and
units countrywide (12,13). Moreover, in 2020, the first
across the world to improve care for our citizens
cardio-oncology rotation for cardiology residents was
affected by cancer.
initiated at the INEN, but unfortunately, it was interrupted by the current coronavirus pandemic. Overall, this unit seeks to enhance the prevention, diagnosis, treatment, and follow-up of patients at risk for car-
AUTHOR DISCLOSURES The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
diotoxicity or who have developed cardiotoxicity second to cancer treatment and, under a research framework, to contribute to the awareness, medical
ADDRESS
education, and development of this new, emerging,
Ruiz-Mori, Universidad de San Martín de Porres, Las
FOR
CORRESPONDENCE:
and critically important subspecialty. Cardio-oncology
Gaviotas 165, Surquillo, Lima 34, Peru. E-mail:
has proven to be a true oncological and medical
cruizm@usmp.pe.
Dr. Enrique
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KEY WORDS cardio-oncology, Peru
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